Author Archives: Nicos Kefalas

‘Let thy food become thy medicine’: healthy diets and supplements in English language self-help books 1950-2000

In this post, Nicos Kefalas (a PhD student with the Balance project) discusses his doctoral research into healthy eating and supplementation. Here he considers why self-help books about diet became so popular in the post-war period, and examines the ways in which this literature deployed linguistic devices to construct readers as “empowered” agents of healthy-lifestyles.

In recent years, it seems that not a day passes by without public debate about healthy eating and supplements. Thousands of magazines, newspapers, websites, YouTube videos and blogs are dedicated to issues revolving around food, diet, exercise, supplementation and health. Popular discussants of healthy diets even make use of data from randomized-control trials (RCTs) and population studies, metastudies and large trials, and translate such knowledge into easily digestible graphics on various foods and supplements to demonstrate whether or not they are truly good for overall good health. (Or to weed out products that could be considered as ‘snake oils’).[1]

My PhD examines the historical emergence and development of healthy eating, dietary advice and supplements to provide a better understanding of when, how, why and by whom ‘Healthmania’ was promoted. [2] ‘Healthmania’ is the fascination of various institutions of the West with healthy diets, foods and supplements, and the concomitant production of advice and products to help individuals attain better lifestyles, both independently and collectively. From the 1950s onwards, self-help literature, lifestyle magazines, newspapers, advertisers, science and the state accepted and promoted certain foods, diets and supplements for a number of reasons. Building upon a widespread valorisation of science on the one hand, and fascination of the media and public with slim bodies and healthy lifestyles on another, leading scientists, public figures and state bodies were all motivated by a mixture of personal ambition and broader political aims to promote healthy eating and supplementation.

Following historical work on Galenic medicine, food and health that has centred on early-modern herbals, manuals and cookery books, I am currently examining English language self-help books published between 1950-2000 which concentrate on nutrition, diets, food and health.

‘HEALTHMANIA’ IN SELF-HELP BOOKS’

Self-help authors made individual agency central to their efforts to popularise ‘optimal’ and ‘ideal’ diets. It is clear that the language and advice in self-help books emphasize and promote the notion that readers have the power to manage their own health and a moral obligation to do so. The books heavily imply that the proactive, educated, well-read and well-informed individual can promote their own good health. The readers are initiated into a self-narrative in which they do not need or want the help of doctors and expensive or ineffective treatments. This newfound agency over their own health is reinforced by the growth of capitalism to provide the foods and supplements necessary to sustain a mentality of ‘buying a better body’. Indeed, not only does the self-help literature direct its readers to the nearest health food stores, pharmacies and juice bars, but it also urges readers to consume specific foods (often exotic fruit), drinks and supplements. Some authors of self-help guides even take a further step. For example, Dr Atkins urges his readers to monitor their progress using a home urine-chemistry kit, encouraging the purchase of sophisticated surveillance technology, alongside expensive dietary consumables and further literature.

One of the reasons behind the popularity of the self-help industry lies in the fact that it stood out from mainstream science and advice for better health, which often consisted of the mantra to ‘eat less, exercise more’. By contrast, whilst self-help books sought to empower readers to make positive changes in the present and future, self-help books nonetheless removed the blame for ill-health and obesity from their readers and instead attributed responsibility for past failures to the food industry, ‘modern foods’, fast foods, mainstream science, and modern lifestyles. Each reader is thus given the chance to feel like a revolutionary and an ‘enlightened’ consumer. This narrative was facilitated through the consistent use of motivational language, tone, expressions and symbolism. Taking Atkins’ book as an example once more, one can see how phraseology and capitalisation of sentences urged his readers to stop being bystanders to the damage done to their bodies by modern foods (namely carbohydrates in this case) and start defending their health. Such phrases were ‘A REVOLUTION IN OUR DIET THINKING IS LONG OVERDUE’ and ‘WE ARE THE VICTIMS OF CARBOHYDRATE POISONING’.[3]

People turned to self-help books because they addressed contemporary anxieties of the everyday individual. The fear of hunger, for instance, is explicitly addressed by the genre as a whole. These authors knew that people fear hunger, because when they are hungry they lose their control of their bodies, and compromise their diets with filling – though not necessarily healthy – foods. In the short-term, authors reassured readers, this was not necessarily an issue. As Robert Haas advised his readers: ‘There is no point in worrying about cheating occasionally’. He noted, however, that such infidelities to his rules were only acceptable if ‘you stick to the Peak Performance Programme in the long run’.[4]

Yet, alongside questions of deprivation, self-help authors had another, seemingly paradoxical, problem to think about, – luxury and efficiency. No one wants to start a boring diet that does not bring the desired results fast enough. Produced at a time when instant gratification of nearly all desires, cravings and wants can be quite simply achieved, self-help books had to portray eating healthily as an easy process coming from filling, varied, tasty and luxurious foods. For example, Atkins argued that people could lose weight on: ‘Bacon and eggs for breakfast, on heavy cream in their coffee, on mayonnaise on their salads, butter sauce on their lobster; on spareribs, roast duck, on pastrami; on my special cheesecake for dessert’.

These and many more themes in the self-help genre play a big part in the popularisation of science and the growth of ‘Healthmania’. The readers of these books are given the knowledge to become active agents of their own health. Change towards better health is elevated to an individualistic and stoic process by which the readers refused to be ill, overweight or obese. The process of becoming healthier offered by the self-help genre is easier with less hunger and more ‘exotic’ and luxurious foods than the average diet recommended by the state and doctors. The advice in these books offers readers a way to avoid the dreaded visits to doctors’ practices, and thus on the surface at least, serves in part to undermine the authority of orthodox medicine. However, even though these books seem to have been against modern scientific theories/practices, self-help authors were using contemporary scientific ideas. These authors offered a self-criticism of the various food and health-related professions they wrote from. They did so by using widely accepted scientific tools and perspectives to criticise orthodox medicine and dietetics from a marginal perspective. Indeed self-help books promoted their advice by using the same tools and analytics (macronutrients, micronutrients, calories, specific foods and supplements, the culture of quantification, and often their authors underwent the same training as their ‘mainstream’ counterparts). By following the advice offered by these books, the readers break out of the complacency to ill-health imposed on them by ‘modernity’ and became part of a reactionary kinship. In these works, health itself became a rational, measurable and quantifiable endeavour. More significantly, though, it became a commodity, leading to the explosion of the supplement industry and ‘Healthmania’ in general.

[1] For instance: http://www.informationisbeautiful.net/visualizations/snake-oil-supplements/

[2] This notion goes beyond the 1980s term coined by Robert Crawford, called healthism which is: ‘the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles’.

[3] R.C. Atkins, Dr Atkins’ Diet Revolution (New York, Bantam, 1972), pp. 3-5.

[4] R. Haas, (British adaptation by A. Cochrane), Eat To Win (Middlesex, Penguin, 1985), p. 157.

A Question of ‘Public Engagement’

Ayesha Nathoo

Over the last year, I have been involved in a number of public events related to my work on the history of therapeutic relaxation. These have included talks, displays and practical workshops at the “Being Human” festival of the humanities, the “Secret Garden Party” and the “Wilderness festival” (in collaboration with Guerilla Science and NOW live events), a “Friday Late Spectacular” and a discussion evening on “Rest and Relaxation in the Modern World” as part of Hubbub, at the Wellcome Collection, London.

The aims, scale, content and audiences varied for each of these events, but together they have left me reappraising my role as a historian, and reflecting on notions of expertise in such public forums. The central topics which comprise my research – ‘rest’, ‘balance’, ‘stress’ and ‘relaxation’ – affect us all, and many audience members were drawn to the events because of pre-existing interests in these matters. Others stumbled across the events by chance with little idea of what to expect or gain from them. In the music festivals, the historical material distinguished my workshops from the myriad other practice-based workshops on offer (such as yoga, mindfulness and massage); elsewhere the practical content differentiated my work from other more traditional academic contributions.

I am particularly interested in understanding relaxation as a taught practice, and the material, audio and visual culture that has furthered its development over the last hundred years in Western, secular, therapeutic contexts. Aural instruction given in classes or on cassettes were key methods for teaching and learning relaxation in the post-war decades and are central to understanding the growth of such practices in both clinical and domestic settings. As well as the instructions, the tone of voice, pace, pauses, and type of medium would have affected how relaxation was understood, distributed and practiced, so I have been keen to track down and share some of the original audio recordings to better understand these experiential and pedagogical aspects. If these have been unavailable I have instead endeavoured to recreate the ways in which different protagonists have taught relaxation, piecing together printed publications, archival material and oral historical resources to do so.

Many of those who participated in the workshops were curious to learn more about the techniques that I discussed – such as yoga, meditation or autogenic training – and their relationship to health and wellbeing. Yet as I was presenting the material primarily as a historian, rather than as a practitioner or advocate of any particular therapeutic practice, some unexpected tensions seemed to arise. Whilst the historical material inspired much interest, most centrally I found that people wanted to evaluate the specific techniques: What was going to work best for them for particular ailments or for general wellbeing? What is the best strategy for alleviating anxiety or chronic pain? Would I recommend relaxation for childbirth? Did I have copies of relaxation instructions that they could take away? Why was I talking about Progressive Muscle Relaxation, one lady asked, when the Alexander Technique (which she had taught for 20 years) was far superior? Was mindfulness meditation really a form of relaxation? Was it best to concentrate on relaxing the mind or the body? What is the evidence base for therapeutic relaxation? Why bother with daily relaxation training if there is a more accessible pharmaceutical option?

Although comparable questions have partly spurred my own interest in this research area, speaking as a historian I have felt uneasy about offering responses. The short, practical, personal questions are not compatible with in-depth answers that address broader medical, social and political contexts, such as the rise of individualism and the mass media, and changes in healthcare, lifestyle and biomedical models. Yet that is what has created and shaped successive demands for and critiques of therapeutic relaxation; contemporary concerns and understandings derive from these past contexts. This is the long and complex narrative that I am researching and whilst I certainly hope that it will have policy implications and be relevant to today’s medical landscape, I do not feel equipped to offer personal advice. Neither am I sure that I should be doing so.

I would speculate that this kind of professional reticence is a majority view amongst historians, and yet it is somewhat frustrating for interested lay audiences. If a professional researcher is investigating a particular subject, then why should they not state their opinions based on the knowledge gained from the research? I have come across this at various other points during past research, on topics ranging from the media coverage of the possible link between autism and the MMR vaccination to organ transplantation and donation. ‘Should I give my child the vaccination?’, mothers repeatedly asked me. ‘Were there any reasons not to sign the organ register?’ ‘Did I think there should be an opt-out clause to increase donation rates?’ It is not that I had not given enough thought to these matters – I had extensively mulled over them – yet I questioned my role as a historian to authoritatively influence other people’s present-day decisions, certainly without allowing the time and space to substantiate my points of view. The aim, however, would not be to give a ‘balanced’ view in the sense of ‘objectively’ presenting a full range of arguments for and against.

The personal is the historical: Knowledge and memories of the past shape views and actions for the future. And so a historian’s personal stance can generally be inferred from their authored work, amongst the layers of interpretations and the selection of sources. Perhaps then scholars should meet the challenge of more explicitly articulating their own views in public contexts, where audience members often lead conversations and set agendas and where the boundaries of expertise are fluid. As ‘public engagement’ becomes an increasingly significant part of academic life, it seems timely and important to open up these discussions.

‘On Balance: Lifestyle, Mental Health and Wellbeing’: Musings on Multidisciplinarity, from a Historian.

Ali Haggett

The first of three major conferences to be held in conjunction with the Lifestyle, Health and Disease project took place on the 25^th and 26^th of June at the University’s Streatham Campus. Focusing broadly on the strand of research that is concerned with mental health and wellbeing, the remit of the conference was to explore the ways in which changing notions of ‘balance’ have been used to understand the causes of mental illness; to rationalise new approaches to its treatment; and to validate advice relating to balance in work and family life. Drawing on a range of approaches and methodologies, the multidisciplinary conference attracted scholars from Britain and the United States, with diverse backgrounds, which included: history, anthropology, psychiatry, psychology and clinical medicine. On the evening of the 24^th June, as a prelude to the event, we began by hosting a public panel debate, on the topic of ‘Defeating Depression: What Hope?’ at the Royal Albert Memorial Museum in Exeter. A photo gallery and a summary of the evening can be found on the Exeter Blog

Still at the formative stages of research, I hoped that the contributions from other scholars might provoke new lines of enquiry, or stimulate interesting alternative approaches to our work. One of the questions I am particularly interested in is: why does the concept of balance in mental health and wellbeing become influential at certain times through our recent history? As the conference progressed, and with the public panel event also in mind, I found myself wondering what a future historian might make of the contemporary themes and concerns that emerged from this conference. It struck me that many of the anxieties that were articulated by non-historians were not new, but that they had surfaced at regular junctures in modern history. At the heart of a number of papers, and evident from the contributions to the public debate, was a palpable dissatisfaction with the status quo – with ‘modern’ and perhaps ‘unbalanced’ ways of living and their effects on health. These concerns are reminiscent of those put forward much earlier, during the early and mid twentieth century, by proponents of the social medicine movement who were critical of rising consumerism, the breakdown of traditional values and kinship ties, and who were keen to reduce the burden of sickness by pressing for social improvements.[1] Misgivings about the current ‘neo-liberal’ political climate were evident, where, in some circles, the principles of free-market individualism are held to undermine collective action, community spirit and kinship, leading to disempowerment and ultimately to ill health. The prevailing interventionist, biomedical model of medicine practised in the West did not escape criticism. Some of the concerns raised resonated strongly with the ideas put forward by proponents of the ‘biopsychosocial’ model of medicine from the 1970s, which highlighted the importance of the social context of disease.[2] A number of papers raised important questions about the ways in which the current medical model appears to foreground the treatment of mental illness and underplay approaches to prevention. Speakers from the conference and contributions to the public debate noted, with some disquiet, that responsibility for protecting and maintaining mental health had increasingly shifted to the individual, instead of the ‘group’, the employer or the wider socio-economic environment.

Perhaps unsurprisingly, anxieties about mental illness and the field of psychiatry that first materialised during the 1960s and developed within the ‘anti-psychiatry’ movement were still conspicuous at the conference – anxieties about the classification, diagnosis and labelling of mental disorders; unease about the misapplication of ‘norms’, rating scales and the concept of ‘risk management’ in medicine. The disquiet that emerged during the 1960s was of course also intimately associated with the contemporary counter culture and broader concerns about the conformity and emptiness of the post-war world. Such ideas were evident in the literature of the period from authors such as George Orwell, William H. Whyte, David Riesman and Herbert Marcuse, who all variously disapproved of the social and cultural changes that took place in mid-century Britain and the United States.[3]

Defined by the Oxford Dictionary as ‘a situation in which different elements are in the correct proportions’, the concept of ‘balance’ remains at the core of all debates about mental health, whether we are talking about chemical imbalance, work-life balance or cognitive and mindful approaches to human behaviour. The papers delivered at the conference by my fellow historians neatly exposed the ways in which many of the themes discussed have emerged in the past and often reveal more about broader concerns, tensions and uncertainty about new ways of living and their effects on health than they do about epidemiological trends in mental illness. While historians are uniquely placed to add this important context, the joy of combining insights from several disciplines is that we are able to begin to redefine problems and reach solutions through new understandings. On a personal level, the contributions from other disciplines reminded me that perhaps, as an idealistic historian, I am sometimes distanced from the harsh realities of clinical practice. Collectively, the papers also prompted me to think about new ways of conceptualising and measuring what is ‘balanced’ in life and in health – and perhaps also to question the ways in which balance is somehow taken to be inherently desirable, or essential. There is no doubt that the global burden of mental ill health has become one of the most pressing social and medical problems of our time. Overcoming the challenges faced will require the knowledge of more than one discipline. As scholars engaged in research into mental health and wellbeing, we are all, in different ways, and with different approaches – and often with different opinions – ultimately seeking a shared goal of fostering ways to improve mental health and wellbeing in our society.

The conference organisers would like to thank the Wellcome Trust for supporting the conference and to the following speakers for their contributions:

Professor David Healy, Dr Matthew Smith, Professor Jonathan Metzl, Dr Nils Fietje, Professor Ed Watkins, Dr James Davies, Dr Ayesha Nathoo, Professor Michelle Ryan, Mr Frederick Cooper, Professor Femi Oyebode, Dr James Fallon and Dr Alex Joy.

[1] As examples: Stephen Taylor, ‘The suburban neurosis’, Lancet, 26 March 1938 and James L. Halliday, Psychosocial Medicine: A Study of the Sick Society (London, William Heinemann, 1948).

[2] See George L. Engel, ‘The need for a new medical model: a challenge for biomedicine’, Science (1977), 196, 129-36.

[3] An interesting discussion of the political and social context within which the antipsychiatry movement grew can be found in Nick Crossley, ‘R. D. Laing and the British anti-psychiatry movement: a socio-historical analysis’, Social Science and Medicine (1998), Vol. 47, No. 7, 877-89.

The Health of Pilots: Burnout, Fatigue, and Stress in Past and Present

Natasha Feiner

On 24 March 2015 a Germanwings Airbus crashed 100 kilometres northwest of Nice in the French Alps after a constant descent that began one minute after the last routine contact with air traffic control. All 144 passengers and six aircrew members were killed.

The crash, tragic as it was, attracted significant media attention and it was not long before attention turned to co-pilot Andreas Lubitz. German prosecutors said that they found indications that Lubitz had concealed an illness from his employer, hiding a sick note on the day of the crash. Whilst some media coverage looked to Lubitz’s history of depression, others investigated ‘burnout’. Der Spiegel reporter Matthias Gebauer tweeted in March that Lubitz was suffering with ‘burnout-syndrome’ when he took time out of pilot training in 2009.[1]

The term ‘burnout’ was coined by Herbert Freudenberger in 1974 and is still widely used in Germany (and to a lesser extent, the UK and America) today. Symptoms include long-term exhaustion and diminished interest in work, which is often assumed to be the result of chronic occupational stress.

The recent media discussion of burnout among pilots as a result of the Germanwings crash has brought the issue of pilot health into sharp relief. Several countries have implemented new cockpit regulations and there has been significant discussion of how pilots (and the airlines that employ them) should best deal with stress, personal problems, and exhaustion. These issues have their historical antecedent in late-twentieth century discussions of ‘pilot fatigue’.

It is widely acknowledged today that commercial airline pilots are employed in one of the most stressful occupations of the modern age. Before the Second World War this issue was rarely discussed outside academic circles. Traditionally conceived by the public as heroic and superhuman, early pilots were held up as paragons of masculine strength and vigour, able to manage great responsibilities with little (if any) impact on their physical or mental health.

Although fatigue was first recognised as a potential problem in the 1950s, it was not until the 1960s that the relationship between flying, fatigue, and the health of pilots was first discussed in the mainstream media. A number of newspaper articles highlighted the stressful nature of the pilot’s job and (from the early 1970s) a number of alarmist articles reported incidents of pilots falling asleep at their controls. In one report a pilot flying over Japan was said to have “nodded off” and then woken to find the rest of his flight crew asleep:

‘In the report… the BOAC captain said that when he felt himself dozing he shook himself, looked around the flight deck and found his two co-pilots and flight engineer asleep. “I immediately called for black coffee to bring everyone round” [he said]’.[2]

The increased media interest in ‘pilot fatigue’ coincided with a period of industrial strife amongst pilots who were experiencing radical changes not only in the type of aircraft they were asked to fly, but also in terms of management and working conditions. These issues came to the fore in 1961 when airline BEA released their summer flying schedules. The proposed schedules were intensive and many BEA pilots questioned the implications for safety. Long duty periods and inadequate rest breaks would, it was argued, cause dangerous fatigue that may increase the likelihood of accidents.

BEA relented and allowed an investigation of ‘pilot fatigue’. Carried out by physician of aeronautics H. P. Ruffell Smith, the investigation used a system of points for measuring flight time limitations, replacing the traditional hours system. The subsequent report suggested that BEA pilots should not fly more than 18 points per day, and extra points were awarded for especially stressful or fatiguing operations, such as take-off and landing. Ruffell-Smith’s report was never published and BEA did not enforce his recommendations. The problem of ‘pilot fatigue’ was not solved.

In the years that followed a number of high profile air disasters occurred, many of which were later attributed to ‘pilot fatigue’. In 1966 a Britannia plane crashed in Ljubljana, Yugoslavia, killing 98 people. One year later another plane crashed, this time in Stockport, killing 72 people. Then, in 1972 a BEA Trident plane crashed in Staines, killing 118 people. The Trident crash, in particular, caught media attention as the pilot in charge of the plane, Stanley Key, had made ‘numerous complaints’ about the length of the working day prior to his death.[3]

As a result of this, in 1972 pilots’ union BALPA revived its campaign to reduce working hours, shifting their focus to the dangers ‘pilot fatigue’ posed to passengers. By emphasising the potential dangers of fatigue, BALPA was able to convince airlines to carry out a further investigation into flight time limitations and pilot workload. Based on the results of the investigation, in 1975 the Civil Aviation Authority published strict regulations on flight times with the aim of avoiding ‘excessive fatigue’[4].

Whilst the problem of ‘pilot fatigue’ did not come to a neat conclusion in 1975 (BALPA continues to campaign on the issue to this day) the working conditions of pilots were drastically improved by the introduction of strict flight time limitations.[5] Such drastic changes would not, arguably, have taken place without the support of the British media. The alarmist nature of newspaper reports on the subject of ‘pilot fatigue’ forced airlines to take the health of pilots seriously, for fear of further frightening (and consequently losing) customers.

One would hope that the British media could play a similarly positive role today, following the Germanwings tragedy, by encouraging a re-evaluation of mental health policy by airlines (as well as by employers more generally). Although many initial newspaper reports about Lubitz were (sadly) insensitive and stigmatising, several recent articles have used a of discussion the Germanwings crash as a platform for encouraging greater awareness and understanding of mental health.[6] The tragedy may yet engender a re-evaluation of mental health and stress in the workplace, as the Trident crash did for ‘pilot fatigue’ in 1972.

[1] Gebauer is quoted in this news report: http://www.independent.co.uk/news/world/europe/germanwings-crash-copilot-andreas-lubitz-who-crashed-plane-suffered-burnout-says-friend-10137076.html [last accessed 23/06/15]

[2] The Times, Dec 13 1972, page 1.

[3] The Times, Nov 29 1972, page 4.

[4] The Avoidance of Excessive Fatigue in Aircrews: Requirements Document, (London, 1975), p. 1.

[5] For more information on BALPA’s current ‘Focus on Fatigue’ campaign see: http://www.balpa.org/Campaigns/Focus-on-Fatigue.aspx [last accessed 23/06/15].

[6] Alastair Campbell (‘Time to Change’ ambassador) on the stigma and taboo surrounding mental health: http://www.huffingtonpost.co.uk/alastair-campbell/andreas-lubitz-would-we-be-blaming-cancer_b_6961386.html [last accessed 23/06/15].